powell chiropractic clinic, inc. - perfect...

Powell Chiropractic Clinic, Inc. Phone: (330) 494-5533 4867 Munson Street, NW Fax: (330) 494-8101 Canton, OH 44718 www.powellchiropractic.com

PATIENT REGISTRATION

Date: / / ___ Home Phone:( ) Work Phone: ( ) Cell :_____________ Patient: Email:___________________________ Last Name First Name Initial Street Address:____________________________________________________________________________ City: State: Zip: Sex M F Age:_________ Birth date: / / Single Married Widowed Separated Divorced

Social Security #: - - Driver’s License #____________________________________ Insured Name: Last Name First Name Initial How and where did you learn about this clinic? __________________________________________________ Relationship To Insured: Self Spouse Child Other Condition/Illness Related To: Illness Employment Auto Other

EMPLOYER

Company Name Occupation Address City State Zip Phone ( ) Full-time Part-Time

SPOUSE (PARENT)

Name Last Name First Name Initial Birth date / / Social Security # - - Employer Name Occupation Address Phone ( ) City State Zip

PATIENT INSURANCE

INFORMATION

Please list any and all insurance and/or employee health care plan coverage you or your spouse have: Insurance Company or Health Care Plan Name Policy/Group #: Effective Date: Name of Insured: ID#:

SPOUSE & CO-

INSURANCE INFORMATION

Please list any and all coinsurance and/or employee health care plan coverage you or your spouse have: Insurance Company or Health Care Plan Name Policy/Group #: Effective Date: Name of Insured: ID#:

Dr. James P. Powell · Dr. James D. Powell · Dr. Robert Powell · Dr. Walter B. Null IV · Dr. Abbey M. Crouse

Powell Chiropractic Clinic, Inc. Dr. James P. Powell · Dr. James D. Powell · Dr. Robert Powell · Dr. Walter B. Null IV · Dr. Abbey M. Crouse

Powell Chiropractic Clinic, Inc.


MEDICAL INFORMATION

++++++++++

LEGAL INFORMATION

Are your present symptoms or conditions related to or the result of an auto accident, work-related injury or other personal injury someone else might be legally liable for?

Yes No Your Initials ____________ If you answered yes, please fill out accident specific form, available at the front desk. Pregnant? Yes No Pacemaker? Yes No Family Physician: ________________________________________________________

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Attorney ____________________________________ Telephone: _______________ ____________________________________________________________________ Address _____________________________________________________________________

Person(s) to contact in case of emergency, questions concerning my treatment, and any questions concerning my account or account balance. Name __________________________________ Telephone #_________________

Relationship ____________________________ Cell Phone #_________________ LEGAL ASSIGNMENT OF BENEFITS AND RELEASE OF MEDICAL AND PLAN DOCUMENTS

In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage with the above captioned, and hereby assign and convey directly to Powell Chiropractic Clinic all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such doctor and clinic. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the doctor to release all medical information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy and/or settlement information upon written request from such doctor and clinic in order to claim such medical benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or employee health benefits claim submissions. I hereby convey to the above named doctor and clinic to the full extent permissible under the law and under the any applicable insurance policies and/or employee health care plan any claim, chose in action, or other right I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health care plan with respect to medical expenses incurred as a result of the medical services I received from the above named doctor and clinic and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation, I agree to cooperate with such doctor and clinic in any attempts by such doctor and clinic to pursue such claim, chose in action or right against my insurers and/or employee health care plan, including, if necessary, bring suit with such doctor and clinic against such insurers and/or employee health care plan in my name but at such doctor and clinic's expenses. Should this assignment be prohibited in part or in whole under any anti-assignment provision of my policy/plan, please advise and disclose to my provider in writing such anti-assignment provision within 30 days upon receipt of my assignment, otherwise this assignment should be reasonably expected to be effective and such anti-assignment is waived. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement. Signature _____________________________________ Date _______/_______/_______


PRACTICE REQUIREMENTS

The Practice:

(a) Is required by federal law to maintain the privacy of your Personal Health Information (PHI) and to

provide you with this Privacy Notice detailing the Practice’s legal duties and privacy practices with

respect to your PHI.

(b) Powell Chiropractic Clinic, Inc. adheres to Ohio law in those instances where Ohio law does not

conflict with federal law.

(c) Is required to abide by the terms of this Privacy Notice.

(d) Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice

provisions effective for all of your PHI that it maintains.

(e) Will distribute any revised Privacy Notice to you prior to implementation.

(f) Will not retaliate against you for filing a complaint.

EFFECTIVE DATE

This Notice is in effect as of 04/15/03. If you would like to review our HIPPA agreement, please advise our staff and we will supply you with detailed information.

PATIENT ACKNOWLEDGEMENT

By subscribing my name below, I acknowledge that I have read this Notice, and that I understand and agree to its terms.

Patient Name

Patient Signature

Date

Please Initial: I am giving permission to leave a message on my home or cell phone: ________ Yes _______No I am giving permission to leave a detailed message on my home or cell phone: ________ Yes _______No

Dr. James P. Powell · Dr. James D. Powell · Dr. Robert Powell · Dr. Walter B. Null IV · Dr. Abbey M. Crouse

Powell Chiropractic Clinic, Inc.


AUTO INSURANCE VERIFICATION FORM

Name: ______________________________________________________________________

Appointment Date: ___________________________ Powell Acct: _____________________

AS PREVIOUSLY EXPLAINED TO YOU, OUR OFFICE POLICY IS TO BILL YOUR AUTO

INSURANCE THROUGH THE MEDICAL CLAUSE IN YOUR POLICY.

YOU MUST PROVIDE US WITH THE FOLLOWING INFORMATION:

1. DATE OF ACCIDENT: ______________________________________________________

2. YOUR AUTO INSURANCE INFORMATION:

a. COMPANY NAME: ________________________________________________

b. ADJUSTER NAME: ________________________________________________

c. INSURANCE MAILING ADDRESS: ____________________________________

________________________________________________________________

d. INSURANCE TELEPHONE NUMBER:_________________________________

e. CLAIM #: ________________________________________________________

3. RESPONSIBLE PARTY INSURANCE INFORMATION

a. COMPANY NAME: ________________________________________________

b. ADJUSTER NAME: ________________________________________________

c. INSURANCE MAILING ADDRESS: ____________________________________

________________________________________________________________

d. INSURANCE TELEPHONE NUMBER:_________________________________

e. CLAIM #: ________________________________________________________


ASSIGNMENT AND AUTHORIZATION

PRIVATE AND GROUP ACCIDENT AND HEALTH INSURANCE

(YOUR INSURANCE/AUTO-MED INFORMATION)

I hereby my insurance company to pay directly

to POWELL CHIROPRACTIC CLINIC, INC., 4867 Munson Street, NW, Canton, Ohio 44718

the TOTAL AMOUNT OF MEDICAL CHARGES payable under the terms of

Policy Number ______________________ Claim Number _________________________,

on claim commencing on or about ___________________________.

I specifically authorize that this assignment may be paid from disability benefits, medical payments, or

from ANY benefits due to me under this claim. I understand and agree that any unpaid balances not

covered by this policy will be paid by me.

I also authorize the above named Doctor/Clinic to release any information, pertinent to my case, to

any insurance company, adjuster or attorney involved in the case.

Dated at Canton, Ohio this ___________ day of ___________________________, 20_______.

_________________________________________________ Signature of Policy Holder _________________________________________________ Witness

I hereby state and agree that a photocopy of this document will be deemed as valid and binding on all

parties involved as the original copy.

Name of Company

Date


ASSIGNMENT AND AUTHORIZATION

PRIVATE AND GROUP ACCIDENT AND HEALTH INSURANCE

(RESPONSIBLE PERSON’S INSURANCE)

I hereby request ______ to pay directly

to POWELL CHIROPRACTIC CLINIC, INC., 4867 Munson Street, NW, Canton, Ohio 44718

the TOTAL AMOUNT OF MEDICAL CHARGES payable under the terms of

Policy Number ______________________ Claim Number ________________________,

on claim commencing on or about ___________________________.

I specifically authorize that this assignment may be paid from disability benefits, medical payments, or

from ANY benefits due to me under this claim. I understand and agree that any unpaid balances not

covered by this policy will be paid by me.

I also authorize the above named Doctor/Clinic to release any information, pertinent to my case, to

any insurance company, adjuster or attorney involved in the case.

Dated at Canton, Ohio this ___________ day of ___________________________, 20_______.

_________________________________________________ Signature of Claimant if other than Policy Holder _________________________________________________ Witness

I hereby state and agree that a photocopy of this document will be deemed as valid and binding on all

parties involved as the original copy.

Name of Company

Date


PATIENT VERIFICATION

I have been advised by this Clinic that the preferred method for payment of treatment is for the fees to be paid directly by me as I receive treatment:

I do not want my health insurance to be billed for treatment of my injuries, except in the case

that my own liability insurer requires it as a condition to qualifying for medical payments

coverage.

I authorize this Clinic to bill my own liability insurer for treatment fees I incur. I authorize this Clinic to

send notice of the Assignment to my own liability insurer, to the liability insurer of the person I claim

caused my injuries, and to the attorney representing me for My Claim. This document is made a part

of the Assignment I have signed in favor of the Clinic.

____________________________________ ___________________________________

Name of Liability Insurer for Person at Fault Name of My Liability Insurer

____________________________________

Name of My Attorney If Applicable

I have received a copy of an Assignment which I have signed in favor of this Clinic and Schedule of

Treatment Fees.

______________________________________________ __________________________

Signature of Patient, Parent or Legal Guardian Date

______________________________________________ __________________________

Print or Type Name Staff Witness


PAYMENT FOR TREATMENT (When Patient's Health Insurance Will Not Be Billed)

I have been injured. I do not have health insurance or do not want my health insurance to pay for the

treatment fees. If my automobile insurance will cover my treatment fees, I authorize this Clinic to bill

this insurer. Even if no other person is at fault for my injuries caused by an accident, agree to sign this

Clinic's Assignment and related documents, and will provide any information required by the Clinic. I

realize that any money which I receive from my automobile insurer for this Clinic's treatment fees must

be immediately paid over to this Clinic.

If I believe that one or more persons are at fault for causing my injuries in an accident, I agree to sign

this Clinic's Assignment and related documents, and will provide any information required by the

Clinic.

I understand that my automobile insurer, or an insurer representing someone I believe to be at fault

for causing my injuries, or that persons' attorney, or an attorney representing me in a claim for injuries,

may request reports, copies of records may require a physician from this Clinic to provide deposition

testimony or testimony in court, or other information. I understand and agree that I am financially

responsible to this Clinic to pay the Clinic's costs for these items, and that the Clinic may request

payment in advance for some or all of these items, even if this Clinic's Assignment states otherwise.

I understand and agree that all of my records, including x-rays, are permanent records of this Clinic. I

authorize the release of any information relevant to my treatment, including information regarding

treatment fees, to insurers and attorneys who are involved with my claim and their respective

representatives.

I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND IT.

THIS DOCUMENT IS PART OF THE ASSIGNMENT I HAVE SIGNED IN FAVOR OF THE CLINIC.

I HAVE RECEIVED A COPY OF THIS DOCUMENT.

______________________________________________ __________________________ Signature of Patient Date

______________________________________________ Print or Type Patient’s Name

______________________________________________ Signature of Parent or Legal Guardian


ASSIGNMENT

I was involved in an accident on or around ______________________ [date] in which I was injured and for which I have or

may have a claim against another person(s) for causing my injuries, including __________________________________

who is insured by___________________________________.

In consideration of the agreement of Powell Chiropractic Clinic Inc. (referenced as the "Clinic") to delay billing me personally

for medical treatment rendered until resolution of This Claim:

1. I now assign, without any right to later revoke a part of any proceeds from my claim equal to the fees incurred by me to

this Clinic for all treatment and other services rendered by this Clinic. I am not assigning any legal cause of action in this

Claim, but only prospective proceeds. I also assign to the Clinic my right to enforce the obligation of any insurance

company to pay settlement proceeds for any settlement agreement made by or for me in exchange for my signing such

insurance company's release of claim. Prior to settlement or other disposition of this claim, I understand and permit the

Clinic to pursue payment from any source other than me personally, including medical payments covered in an

automobile liability policy.

2. This Assignment and related documents which I have signed in connection with it states the entire agreement

and my complete understanding regarding the Clinic's fees. I have not relied on any statements by the Clinic or

the Doctor or other information before making this Assignment. I understand that I remain responsible for any

Clinic fees not paid out of this Claim.

_________________________________________ Signature of Patient

3. I understand that it is my responsibility during treatment to remain aware of my cumulative account balance for

services rendered. I have received a schedule of treatment fees for this Clinic, or if I have not, will request this

Clinic for one in writing.

4. I understand that this is an express contract to pay for the services rendered by this Clinic. I agree to pay my account

balance in full and/or direct its payment from My Claim proceeds regardless of whether any other person or entity

attempts to or fails to fully reimburse me for it. If I dispute my account balance or treatment rendered, I agree that my

remedy will be to resolve it with a separate action from My Claim.

5. NOTICE: I DIRECT ANY INSURANCE COMPANY, ATTORNEY, OR OTHER PERSON WHO HOLDS OR LATER

HOLDS ANY PROCEEDS FROM THIS CLAIM TO APPLY ANY PROCEEDS FROM THIS CLAIM TO MY TOTAL

ACCOUNT BALANCE OUT OF THE TOTAL PROCEEDS HELD IN MY BEHALF, UNLESS THE CLINIC CONFIRMS

PRIOR PAYMENT OF IT IN WRITING. "TOTAL PROCEEDS" HELD BY AN ATTORNEY FOR THIS CLAIM SHALL

MEAN PROCEEDS AFTER DEDUCTION OF ATTORNEY FEES.

6. This Assignment is governed by Ohio law. Jurisdiction shall be in Ohio, and venue shall lie in the county in which the

Clinic is located, unless required by applicable law to lie in a different county than which I reside.

7. I REALIZE THAT I HAVE NOW GIVEN AWAY A PART OF ANY PROCEEDS FROM THIS CLAIM. IF I RECEIVE

ANY PROCEEDS FROM THIS CLAIM, I AGREE TO IMMEDIATELY DETERMINE IF THIS CLINIC HAS BEEN

SEPARATELY PAID IN FULL. UNLESS THE CLINIC CONFIRMS FULL PAYMENT IN WRITING, I REALIZE THAT

ANY USE BY ME OF THESE PROCEEDS IS TAKING OR CONVERTING MONEY THAT IS THE PROPERTY OF

THIS CLINIC.

8. I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND IT.

_____________________________________________________ ___________________________________

Signature of Patient Date

_____________________________________________________ This Assignment Has Been Signed On The

Print or Type Patient’s Name Clinic Premises:

_____________________________________________________ ___________________________________

Signature of Parent or Legal Guardian Staff Witness

Name of Person at Fault

Copyright 1999 John P. Lowry, Esq.

Boehm, Kurtz & Lowry, Attorneys at law


UPDATED PATIENT INFORMATION We are in the process of updating our records to comply with federal standards,

please answer the following questions:

Patient: _____ Date: ________________ Last Name First Name Initial

Preferred Language?

English Spanish Other__________________________

Race?

I do not wish to provide this information.

White Black or African American

American Indian or Alaska Native Asian

Native Hawaiian or Other Pacific Islander Other __________________________

Ethnicity?

I do not wish to provide this information. Hispanic or Latino

Non-Hispanic or Non-Latino Other __________________________

Smoking Status?

Current every day smoker: How many packs/day? ___________________

Current some day smoker: How many packs/week? ___________________

Former smoker

Never smoker

Do you have any medication allergies?

No known medication allergies

Yes. What? __________________________________________________________

Are you currently taking any medications (prescription or over-the-counter)?

Not currently taking any medications

Yes… What? ______________________________ _______ mg

What? ______________________________ _______ mg

What? ______________________________ _______ mg


Do you take vitamins or other supplements?

Not currently taking any vitamins or supplements

Yes… What? ______________________________ _______ mg or times/day

What? ______________________________ _______ mg or times/day

What? ______________________________ _______ mg or times/day

Have you had recent tests showing high cholesterol and/or triglycerides? Yes No

Have you had recent tests showing high blood pressure? Yes No

Are you diabetic? Yes No Are you taking insulin? Yes No

Do you eat breakfast daily? Yes No

How many days/week do you skip one or more meals? 0-1 2-3 4 or more

How many servings of vegetables do you eat/day (average)? 0-1 2-3 4 or more

How many servings of fruit do you eat/day (average)? 0-1 2-3 4 or more

How many times do you eat fast-food or refined/processed foods a week (average)? 0-2 3-5 6-8 9 or more

What are your average hours of sleep/night? 0-3 4-5 6-7 8 or more

Do you need to take pills to sleep or be able to relax? Yes No

Have you received the full, standard profile of vaccinations? Yes No

Have you had the flu shot this year? Yes No

Have you had flu shots in the past? Yes No

Patient Name:

NECK DISABILITY INDEX QUESTIONNAIRE

LAST NAME: _____________________ FIRST

This questionnaire is designed to help us better understand how your neck pain affects your ability to

life activities.

Please mark the one that most closely describes your present day situation in each section.SECTION 1 - PAIN INTENSITY

�I have no pain at the moment.

�The pain is very mild at the moment.

�The pain is moderate at the moment.

�The pain is fairly severe at the moment.

�The pain is very severe at the moment.

�The pain is the worst imaginable at the moment.

SECTION 2 - PERSONAL CARE (Washing, Dressing,etc.)

�I can look after myself normally without causing extra pain.

�I can look after myself normally, but it causes extra pain.

�It is painful to look after myself, and I am slow andcareful.

�I need some help but manage most of my personal care.

�I need help every day in most aspects of self

�I do not get dressed. I wash with difficulty and stay in bed

SECTION 3 – LIFTING

�I can lift heavy weights without causing extra pain.

�I can lift heavy weights, but it gives me extra

�Pain prevents me from lifting heavy weights off the floor but I can manage if items are conveniently positioned, ie. on a table.

�Pain prevents me from lifting heavy weights, but I can manage light weights if they are conveniently positioned.

�I can lift only very light weights.

�I cannot lift or carry anything at all.

SECTION 4 – READING

�I can read as much as I want with no neck pain.

�I can read as much as I want with slight neck pain.

�I can read as much as I want with moderate neck pain.

�I can't read as much as I want because of moderate neck pain. �I can't read as much as I want because of severe neck pain.

�I can't read at all.

SECTION 5 – HEADACHES

�I have no headaches at all.

�I have slight headaches that come infrequently.

�I have moderate headaches that come infrequently.

�I have moderate headaches that come frequently.

�I have severe headaches that come frequently.

�I have headaches almost all the time.

NECK DISABILITY INDEX QUESTIONNAIRE

LAST NAME: _____________________ FIRST NAME: ___________________ MI: ____ Date: ____________________

This questionnaire is designed to help us better understand how your neck pain affects your ability to

lease mark the one that most closely describes your present day situation in each section. SECTION 6 – CONCENTRATION

�I can concentrate fully without difficulty.

�I can concentrate fully with slight difficulty.

�I have a fair degree of difficulty concentrating.

�I have a lot of difficulty concentrating.

�I have a great deal of difficulty concentrating.

The pain is the worst imaginable at the moment. �I can't concentrate at all.

PERSONAL CARE (Washing, Dressing,etc.) SECTION 7 – WORK

look after myself normally without causing extra �I can do as much work as I want.

I can look after myself normally, but it causes extra pain. �I can only do my usual work, but no more.

It is painful to look after myself, and I am slow and �I can do most of my usual work, but no more.

I need some help but manage most of my personal care. �I can't do my usual work.

I need help every day in most aspects of self -care. �I can hardly do any work at all.

wash with difficulty and stay in bed. �I can't do any work at all.

SECTION 8 – DRIVING

I can lift heavy weights without causing extra pain. �I can drive my car without neck pain.

I can lift heavy weights, but it gives me extra pain. �I can drive as long as I want with slight neck pain.

Pain prevents me from lifting heavy weights off the floor but I can manage if items are conveniently positioned, ie.

�I can drive as long as I want with moderate neck pain.

prevents me from lifting heavy weights, but I can manage light weights if they are conveniently positioned.

�I can't drive as long as I want because of moderate neck pain.

�I can hardly drive at all because of severe

�I can't drive my car at all because of neck pain.

SECTION 9 – SLEEPING

I can read as much as I want with no neck pain. �I have no trouble sleeping.

want with slight neck pain. �My sleep is slightly disturbed for less than 1 hour.

I can read as much as I want with moderate neck pain. �My sleep is mildly disturbed for up to 1

I can't read as much as I want because of moderate neck �My sleep is moderately disturbed for up to 2

I can't read as much as I want because of severe neck pain. �My sleep is greatly disturbed for up to 3

�My sleep is completely disturbed for up to 5

SECTION 10 – RECREATION

�I have no neck pain during all recreational activities.

I have slight headaches that come infrequently. �I have some neck pain with all recreational activities.

moderate headaches that come infrequently. �I have some neck pain with a few recreational activities.

I have moderate headaches that come frequently. �I have neck pain with most recreational activities.

I have severe headaches that come frequently. �I can hardly do recreational activities due to neck pain.

�I can't do any recreational activities due to neck pain.

Date: ____________________

This questionnaire is designed to help us better understand how your neck pain affects your ability to manage everyday

I can concentrate fully without difficulty.

I can concentrate fully with slight difficulty.

I have a fair degree of difficulty concentrating.

entrating.

I have a great deal of difficulty concentrating.

I can do as much work as I want.

I can only do my usual work, but no more.

I can do most of my usual work, but no more.

I can hardly do any work at all.

I can drive my car without neck pain.

I can drive as long as I want with slight neck pain.

I can drive as long as I want with moderate neck pain.

I can't drive as long as I want because of moderate neck

I can hardly drive at all because of severe neck pain.

I can't drive my car at all because of neck pain.

My sleep is slightly disturbed for less than 1 hour.

My sleep is mildly disturbed for up to 1-2 hours.

My sleep is moderately disturbed for up to 2-3 hours.

My sleep is greatly disturbed for up to 3-5 hours.

My sleep is completely disturbed for up to 5-7 hours.

I have no neck pain during all recreational activities.

I have some neck pain with all recreational activities.

I have some neck pain with a few recreational activities.

I have neck pain with most recreational activities.

I can hardly do recreational activities due to neck pain.

I can't do any recreational activities due to neck pain.

REVISED OSWESTRY


Please select one answer for each question:

Section 1 - Pain Intensity

� The pain comes and goes and is very mild.

� The pain is mild and does not vary much.

� The pain comes and goes and is moderate.

� The pain is moderate and does not vary much.

� The pain comes and goes and is severe.

� The pain is severe ad does not vary much.

Section 2 -- Personal Care (Washing, Dressing, etc.)

� I would not have to change my way of washing or dressing in order to avoid pain � I do not normally change my way of washing or dressing even though it causes some pain.

� Washing and dressing increases the pain, but I manage not to change my way of doing it.

� Washing and dressing increases the pain and I find it necessary to change my way of doing it.

� Because of the pain, I am unable to do some washing and dressing without help.

� Because of the pain, I am unable to do any washing or dressing without help.

Section 3 – Lifting

� I can lift heavy weights without extra pain.

� I can lift heavy weights but it gives extra pain.

� Pain prevents me from lifting heavy weights off the floor

� Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, for example on a table.

� Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.

� I can only lift very light weights, at the most

Section 4 – Walking

� Pain does not prevent me from walking any distance.

� Pain prevents me from walking more than one mile.

� Pain prevents me from walking more than ½ mile.

� Pain prevents me from walking more than ¼ mile

� I can only walk using a cane or crutches

� I am in bed most of the time and have to crawl to the toilet.

Section 5 – Sitting (“Favorite chair” includes a recliner.):

� I can sit in any chair as long as I like without pain.

� I can only sit in my favorite chair as long as I like

� Pain prevents me from sitting more than one hour.

� Pain prevents me from sitting more than ½ hour.

� Pain prevents me from sitting more than 10 minutes.

� Pain prevents me from sitting

OSWESTRY DISABILITY INDEX QUESTIONNAIRE


Section 6 – Standing (Remember, standing is NOT walking.):

� I can stand as long as I want without pain.

� I have some pain while standing, but it does not increase with time.

� I cannot stand for longer than 1 hour without increasing pain.

� I cannot stand for longer than ½ hour without increasing pain.

� I cannot stand for longer than 10 minutes without increasing pain.

� I avoid standing, because it increases the pain straight away.

(Washing, Dressing, etc.) Section 7 -- Sleeping

I would not have to change my way of washing or dressing in � I get no pain in bed.

I do not normally change my way of washing or dressing even � I get pain in bed, but it does not prevent me from sleeping well.

Washing and dressing increases the pain, but I manage not to � Because of pain, my normal night’s sleep is reduced by less than one than one quarter.

Washing and dressing increases the pain and I find it necessary � Because of pain, my normal night’s sleep is reduced by less than one half.

Because of the pain, I am unable to do some washing and � Because of pain, my normal night’s sleep is reduced by less than one than three-quarter.

Because of the pain, I am unable to do any washing or dressing � Pain prevents me from sleeping at all.

Section 8 – Social Life

� My social life is normal and gives me no pain.

� My social life is normal but increases the degree of pain.

weights off the floor � Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g. dancing,etc.

Pain prevents me from lifting heavy weights off the floor, but I , for example on a

� Pain has restricted my social life and I do not go out as often.

Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.

� Pain has restricted my social life to my home.

� I have hardly any social life because of pain.

Section 9– Traveling

Pain does not prevent me from walking any distance. � I get no pain while traveling.

prevents me from walking more than one mile. � I get some pain while traveling, but none of my usual forms of travel make it any worse.

Pain prevents me from walking more than ½ mile. � I get extra pain while traveling, but it does not compel me to seek alternative forms of travel.

Pain prevents me from walking more than ¼ mile � I get extra pain while traveling which compels me to seek alternative forms of travel.

� Pain restricts me for all forms of travel.

I am in bed most of the time and have to crawl to the toilet. � Pain prevents all forms of travel except that down lying down.

recliner.): Section 10 – Changing Degree of Pain

I can sit in any chair as long as I like without pain. � My pain is rapidly getting better.I can only sit in my favorite chair as long as I like � My pain fluctuates but overall is definitely

Pain prevents me from sitting more than one hour. � My pain seems to be getting better but improvement is slow at the present.

Pain prevents me from sitting more than ½ hour. � My pain is neither getting better nor worse.prevents me from sitting more than 10 minutes. � My pain is gradually worsening.

� My pain is rapidly worsening.


(Remember, standing is NOT walking.):

I can stand as long as I want without pain.

I have some pain while standing, but it does not increase with

I cannot stand for longer than 1 hour without increasing pain.

½ hour without increasing pain.

10 minutes without increasing

I avoid standing, because it increases the pain straight away.

pain in bed, but it does not prevent me from sleeping

Because of pain, my normal night’s sleep is reduced by less



Pain prevents me from sleeping at all.

My social life is normal and gives me no pain.

My social life is normal but increases the degree of pain.

Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g. dancing,etc.

Pain has restricted my social life and I do not go out as often.

e to my home.

I have hardly any social life because of pain.

I get some pain while traveling, but none of my usual forms of

I get extra pain while traveling, but it does not compel me to

I get extra pain while traveling which compels me to seek

Pain restricts me for all forms of travel.

Pain prevents all forms of travel except that down lying down.

Changing Degree of Pain

My pain is rapidly getting better.

My pain fluctuates but overall is definitely getting better.

My pain seems to be getting better but improvement is slow

My pain is neither getting better nor worse.

powell chiropractic clinic, inc. - perfect...

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